Computers Add New Twists To Medical School Training

"Physicians will not be able to practice medicine in the next century without computers. Individual hospitals and medical centers will have their own intranets, as will health care systems." Robert Trelstad,Professor and Chairman of Pathology and Laboratory Medicine,Robert Wood Johnson Medical School. THE TIME FACTOR: Southwestern’s M. David Low says medical school faculty may worry about development time for computer-based instruction. Most physicians and educators agree that computers are worthwhile investments for medical schools. They have revolutionized access to information and allowed institutions to incorporate self-learning tutorials into their curricula. In some cases, computer-simulated surgical procedures are being used to train physicians. There are even devices being developed that permit the user to "operate" in virtual reality. As the computer dramatically alters the way medicine is taught and becomes a standard, indispensable part of the biomedical researcher's arsenal, scientists see those with up-to-date computer skills as having advantages in getting jobs. At the same time, many institutions with hopes of developing computer-based curricula are struggling to overcome a lack of financial resources and administrative support, as well as faculty reluctance. IN REALITY: Dartmouth’s Joseph O’Donnell believes computer-based cases can be more meaningful and in context for the student. "As the pressures for practice time and to do research mount, this is a way to have engaging, interactive learning," notes Joseph O'Donnell, senior advising dean at Dartmouth Medical School. "It requires a faculty member to develop it-along with the necessary support staff help-but the students can use it themselves and interact with other students and not need a faculty member there necessarily. Education becomes more efficient." Yet some medical schools hesitate to jump head-first into the computer age, noting that the costs are high and the technologies are unproven. "I don't think that anyone is really against incorporating technology into medical education," explains Charles Friedman, director of medical informatics at the University of Pittsburgh Medical Center. Rather, he says, the issue is how technology can be used reasonably and most effectively for the money invested. At last count, 118 medical schools offered some form of computer-assisted instruction, according to the American Association of Medical Colleges (AAMC) in Washington, D.C. Supporters believe that computers are changing the way schools teach medicine and allied health professions, fostering a more active learning process as opposed to the passive learning of lecture classes. Computers increase access to information, permit more "practice time" using case simulations, and allow students to study at their own pace-in essence, teaching them how to continue to learn. Computer-enhanced medical education is definitely the wave of the future, according to W. Bosseau Murray, an associate professor of anesthesia at Penn State University's Milton S. Hershey Medical Center. "Right now we practice and train physicians-to-be by random opportunity," he notes. "We would like to give a student more easily diagnosable and planned examples." Computer simulations permit that, although he concedes that "the fidelity of some simulations is not that good." Hershey established a Simulation Development and Cognitive Science Laboratory in 1993. The lab's centerpiece is a lifelike, computer-driven human simulation that imitates the human body's processes. It is used to help teach anesthesia residents, nurses, and medical students the basics and intricacies of operating-room procedures. Actual case situations are practiced on the simulator, which includes a mannequin. CASES COME ALIVE: Darmouth Medical School uses computer-aided interactive case studies on arthritis, cancer, heart disease, and anemia, among others, to teach students how to diagnose and treat disorders. The computer programs suggest alternatives to both diagnoses and treatments in an attempt to prompt students to resolve problems themselves. Many schools are using computers to lessen their reliance on the textbook. At the Robert Wood Johnson (RWJ) Medical School in New Brunswick, N.J., the department of pathology has gone digital. Robert Trelstad, professor and chairman of pathology and laboratory medicine, explains the move: "Physicians will not be able to practice medicine in the next century without computers. Individual hospitals and medical centers will have their own intranets, as will health care systems." Physicians will use computers for tasks such as obtaining reference materials, updating research, and record-keeping, he says. He sees little down side. Computer modules are introduced to medical students in their first two years to help them learn basic sciences in the context of patient cases. "We don't feed them information," Trelstad says of the problem-based learning curriculum. In the third and fourth years of medical school, computerized cases enhance-not replace-hands-on training in the clinic. DO-IT-YOURSELF: Vinay Kumar of Southwestern sees computer-based education as perfect for students who want to teach themselves. Vinay Kumar, a professor of pathology at University of Texas (UT) Southwestern Medical Center at Dallas, reports that his medical school adopted computers because traditional lectures failed to put medicine into the context of actual patient cases for the first- and second-year students. For the past three years, the school has used computers within a hybrid curriculum of traditional lecture- and problem-based learning, in which students learn both basic sciences and the clinical reasoning involved in practicing medicine by exploring clinical problems. This hybrid curriculum entails group discussions and lectures in basic sciences such as pathology, physiology, anatomy, and histology. At the same time, students study computerized cases and images on their own. The curriculum changes the relationship between student and faculty, explains Anthony Frisbie, an assistant professor of biomedical communications and senior educational consultant at UT-Southwestern. "The student already has information about the patient and context. The questions [for the instructor] are further downstream and more carefully thought out." Using the case-based approach, Kumar reports, the medical school reduced pathology lectures by 60 percent and developed 100 computerized cases to allow students to learn independently. The same professors and instructors who were spending several hours in preparation for lectures now spend more time as facilitators, interacting with the students in group discussions. Most professors have neither the time nor the expertise to develop the case studies on the computer. Rather, they serve as content experts for software-development specialists. A BETTER MOUSETRAP: Hershey’s W. Bosseau Murray wants the fidelity of computer simulations to improve. Dartmouth medical oncologist O'Donnell and colleagues have used a grant from the National Library of Medicine to develop computer-aided interactive studies in oncology and hematology for first- and second-year students. The six-year-old curriculum-among the first and most progressive in the United States-features computerized case studies on heart disease, arthritis, cancer, and anemia; other programs are being developed. The computer programs guide students through patient cases, through which they are challenged and taught to understand, diagnose, and treat. They suggest several alternatives for both diagnoses and treatments in an attempt to prompt students to resolve problems themselves. The programs are even "empathic," O'Donnell explains, prompting and encouraging students, rather than merely giving yes-and-no evaluations. "We try to encourage students to work in groups, and attempt to make it fun," he comments. O'Donnell points out that for several subjects, large faculty seminars and lectures have been supplanted by group study of computerized cases. "Is the quality different?," he asks. "Perhaps. But the students are learning themselves [outside the classroom], and it's more meaningful and in context." He adds that "third- and fourth-year students are able to see live patients, then review similar cases later on the computer [for practice]." O'Donnell notes that at least half of the curricula's first two years is lecture-based, "even with the problem-based learning that we have in place. We want to get the students more active in their learning. When you have a patient, you need to be able to use the computer as a tool to get information to help you, rather than try to keep all of the information in your head." TRUE BELIEVER: Thomas Krummel of Hershey Medical Center believes the future of surgical training lies in virtual reality devices. VIRTUAL SURGERY: Hershey Medical Center invested $40,000 in a pair of devices called the PHANToM, a training system that enables residents to practice performing surgical procedures on a virtual patient they view through a headset, above right Though most schools provide access to computers, perhaps in the library or in a dedicated laboratory, many are still groping for the computer's proper niche in medical curricula. Some medical schools are grappling with the issues of computer course development, including faculty time and institution expense. Gerald Bartlett, professor and chairman of pathology at the University of Illinois College of Medicine, asked, in an E-mail interview with The Scientist, where would institutions that are "facing many years of shrinking resources-including state support for education, research support, federal support for residency training, clinicians' time for teaching, and the pressures of managed care-find the resources to free up faculty time to develop, maintain, and upgrade instructional computer material?" PROCEED CAUTIOUSLY: Michigan State’s Richard Stahlhut warns medical schools to be sure of their needs before spending on computer-based education. And some question the computer's ability to improve students' learning. Richard Stahlhut, associate director of the Center for Applied Medical Information at Michigan State University Kalamazoo Center for Medical Studies, advises medical schools that want to revamp their curriculum and incorporate computers to be sure of their uses. First, he suggests, schools should diagnose the problem. Why aren't students learning as well as possible, and what can be done? Only about 10 percent of the faculty at the Universi-ty of Texas Health Science Center in Houston are using computers in their courses, according to president M. David Low. He notes that many faculty members are worried about the extra time and work involved. One concern is whether developing classroom material will take time away from research. "It depends on who you talk to and how they have decided to use the technology," says Low. "If someone dives in and decides to incorporate it into the curriculum, then it can be time-consuming. It takes an incredible amount of time-perhaps 100 hours' development time for one hour of computer class time-to perfect. Few faculty will commit to it because they worry that it would require so much time." Albert Salas, AAMC staff associate in medical education, agrees that effectively learning and using new technologies requires a major time commitment. Faculty members, he notes, "need to learn the new software, how to handle it in the classroom and with students, and to evaluate it and its products. It's difficult to choose which technology [to use], and then how to integrate it into the curriculum." Many, he says, are still figuring out the basics. "Most are just beginning to get involved-some more heavily than others-in computers and medicine." UT-Southwestern's Kumar contends that the academic scientist-teacher would be burdened in the first year in developing the case studies and material for the computer. "It initially would increase the time spent to design case studies for the course," he concedes. His department is in its third year of computer-based teaching. Eventually, though, the computerized materials would be great time-savers, and the individual would have to do little to prepare for classes, he predicts. Lectures would be at a minimum. In some cases, faculty members may be resistant to incorporating computer learning into the curriculum, notes educational psychologist Kenneth M. Williamson, an assistant professor of medicine and director of education design at the Medical College of Ohio, Toledo. "They may not see the benefits. The attitude, 'I learned it this way and you can, too,' is often pervasive at first. For any new technology to be successful, it has to be accessible and well-supported, and be viewed as useful by the instructors." Some critics contend that computers remove the fraternal aspect of education, depersonalizing medicine and medical training. They also point out that while today's technology will potentially forever alter the way medicine is practiced, some physicians will attempt to rely too much on the computer for decision-making. A computer, they say, will not help student physicians develop empathy for patients and families. POSITIVE THINKER: Allegheny’s Sheila Katz believes that computers will only continue to enhance medical education. "Computers are wonderful learning tools, but they will never replace some things, like physical diagnosis," says Sheila Katz, a professor of pathology and laboratory medicine and special assistant to the president of Allegheny University of the Health Sciences in Philadelphia. She points to problem-based learning as an example of how motivated students are using technology to find answers to medical problems, learning by themselves and in small groups to analyze and solve a clinical problem. At Allegheny's School of Public Health, all students use a problem-based learning system. A TEACHING 'APPLIANCE': Medical College of Ohio's Kenneth Williamson believes computers will become "just another tool" to help teach students. Some researchers believe that computers can't make mainstream medical education any more depersonalized than it already is. "What could be more depersonalizing than sitting in a room and being lectured at?" asks Williamson. "Computer-based learning allows group discussions of cases and of basic sciences, and time for interaction." Stahlhut thinks that technology can make doctors more humane. Computers give rapid access to information both for them and their patients so they don't have to "know it all," he comments. He argues that doctors should take time away from fact-storing and instead devote it to patient communication and analytical skills. There is no doubt that the future physician-scientist must be computer-literate. Some, like Hershey Medical Center surgeon Thomas Krummel, are convinced that virtual reality holds the key to future surgical training. Krummel, who is professor and chairman of the department of surgery, convinced his institution to invest $40,000 in a pair of surgical devices called the PHANToM. The device is a training system that enables surgeons to practice in a virtual environment and cut down on operating-room time by being prepared for both normal and crisis situations. Surgical residents don a headset through which they can see a virtual patient and subsequently practice performing a surgical procedure. Others see future medical training relying on increasingly available electronic resources. One example is the National Library of Medicine's Visible Human Project. This digital database of body images from MRI, computed tomagraphy, and high-resolution photography is available on the Internet (http://www.nlm.nih.gov/research/visible/). While medical schools cautiously turn to computer-based education, some contend that the next generation of biomedical researchers will ride the wave of cyberspace-based medical education into new career opportunities. Allegheny's Katz thinks that initially, those physician-scientists who are prepared to use computers as "standard operating procedure" will "take the lead in jobs and research opportunities" in academe. Medical College of Ohio's Williamson agrees that such scientists will have the advantages in job opportunities. He also notes that the computer will become a routine part of the physician's day, and inevitable for survival in medicine and science. "It's hard to imagine scientists not already skilled in doing literature searches and accessing the information they need," he says. Physicians need those same skills. "Imagine trying to practice today without knowing how to use a telephone or drive a car," Williamson adds. "I think most faculty adopt technology when they see how it is useful to them. Eventually computers become another appliance, just another tool to help them do what they want. Students -- physicians -- need to feel comfortable with medical informatics and know how to access the information they need."

Computers Add New Twists To Medical School Training

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